1 big thing: Slow start for ACA enrollment

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Enrollment through the Affordable Care Act's exchanges is getting off to a somewhat sluggish start, compared to the last sign-up period.

By the numbers: A little over 370,000 people selected plans through HealthCare.gov in the first 3 days of open enrollment, according to figures the Health and Human Services Department released yesterday.

By contrast, more than 600,000 people selected plans in the first 4 days of the last enrollment period.

Roughly 1 million fewer people have visited HealthCare.gov.

Between the lines: This is a pretty straightforward apples-to-apples comparison of the first few days of enrollment. Last year's totals include one extra day, but it's hard to imagine how that could explain a 40% drop in sign-ups.

There's still time for things to turn around: This report covers the first week of a 6-week enrollment window, and sign-ups usually surge at the end.

"Overall, it’s just too soon to draw any meaningful conclusions from this data aside from the fact that demand remains strong," said Get America Covered, the pro-ACA enrollment organization aiming to make up for some of the cuts to federal outreach programs.

Meanwhile, HHS released a new proposed rule yesterday on "program integrity" for the exchanges.

It's mostly technical changes to the processes for determining people's eligibility. Among the more interesting proposals: HHS wants to let the exchanges cast a wider net when checking to see whether people buying coverage on the exchanges are also enrolled in Medicare.

The system can cancel people's exchange coverage if it finds such a redundancy.

2. HHS finalizes new contraception rules

Another significant change in HHS' program integrity rule: The department wants insurers to send consumers separate bills for medical coverage and whatever coverage they might provide for abortion.

How it works: Federal law says federal funding — including premium subsidies under the ACA — can't be used to cover abortion, and requires insurers to segregate the money they use to provide coverage for abortion services.

That segregation will need to include a whole separate billing process if this proposed rule is finalized.

HHS said insurers should "send an entirely separate monthly bill to the consumer for only the portion of premium attributable to abortion coverage" — which, according to earlier policy outlines, could be as low as $1.

On a similar note, HHS also finalized rules yesterday making it easier for employers to opt out of the ACA's contraception mandate if they have religious — or, in some cases, moral — objections to birth control.

Small businesses, schools, insurance companies and individuals can claim either a religious or moral exemption.

Large, for-profit employers do not appear to be able to claim the moral exemption, but non-profits and small businesses can.

The other side: ACA legal expert Nicholas Bagley has argued that the exemption for moral objections is illegal.

3. Big couple of days for weed

Between the midterms and Jeff Sessions’ departure as attorney general, medical marijuana is really … riding high. (I’m so sorry.)

Driving the news: Shares of the medical marijuana company Tilray surged after Jeff Sessions resigned as attorney general. Sessions was ardently opposed to legal weed. (“Good people don’t smoke marijuana,” he once declared.)

Sessions’ resignation came right on the heels of the midterm elections, in which states approved 3 big marijuana-related ballot initiatives.

In North Dakota, however, a measure to legalize recreational use failed.

Why it matters: Marijuana could be an effective alternative to opioids for pain treatment. And Tuesday’s ballot measures are part of a partial but undeniable shift toward broader legalization — a shift that Sessions decidedly did not facilitate.

A similar divide has played out in Congress, where older lawmakers are generally more resistant to looser pot laws.

5. It's all about the states now

Tuesday’s congressional elections will likely have the effect of pushing policymaking away from Congress and into the states, the Kaiser Family Foundation’s Drew Altman writes in his latest Axios column.

What to watch: Blue states will continue to go their own way, trying to strengthen regulations to control costs, protect consumers and improve their Medicaid programs.

In Congress, divided government will put most major legislation out of reach, and Democrats running for president in 2020 will be more focused on carving out their own health care niches than helping to build a common Democratic agenda, Altman writes.

The bottom line: Proposals in Congress and on the campaign trail are important because they can shape the agenda after 2020. But for now, the states are where the real action is.